Acute Appendicitis
A Prospective Study Of 128 Cases In 2nd
March Hospital-Sebha
Khalifa M. Alayat,* Abdulhafid M. A. Zain,* Amer
Tawati Benirhuma,* Einass. M .Elhudairy,*
Summary
In a prospective study, 128 patients
diagnosed as acute appendicitis were admitted to general surgery department of
2nd March hospital.72 were male, 56.25%, with mean age of 24.5 yrs
and 56 were female, 43.75%, with mean age 23.5 yrs. Total mean age of 24 yrs
range 4-66 yrs.
32 cases are perforated, 25%. 11 cases
presented with periappendicular mass, 8.59%. 15 patients operated with normal
appendix 12.8%.
7 patients developed wound infection
5.98%, all were perforated.
Key
words: Acute appendicitis,
complications, risk factors.
Introduction:
Appendicitis remains the most common surgical
emergency of the abdomen. Early consultation followed by suspicion, diagnosis,
admission, and early appendicectomy, is the mainstay in the management of acute
appendicitis, and the prevention of the pre- and postoperative complications.
Earlier in the 19th century Melier gave
a classical description of appendicitis and stated that it was often
responsible for pain in the right lower abdomen, and can be curable by
appendicectomy.6
In 1887 Morton first successfully removed the
appendix with the intention of curing appendicitis.6
In 1902 Sir Fredrick Treves did much to popularize
the condition by removing the appendix of the Prince of Wales.6
Aim
of the study:
This prospective study is aimed to study
epidemiology of acute appendicitis in this part of the country with special
regard to the incidence of normal appendix and incidence of perforation with
possible risk factors.
Materials and methods:
This prospective study included 128 patients
admitted to 2nd March teaching hospital of Sebha medical college. We
received pts From Sebha city and referred cases from other 5 regional hospitals
ranging 70-200 Kms far.
The study period was from 1st January
2002 till 31st December 2002. It included patients diagnosed as
acute appendicitis with or without complications (perforation, mass).
Investigations were urgently performed, Hb, TLC,
DLC, Blood sugar, urea, serum electrolytes and CXR.
ECG was performed for patients aged 40 and above.
Ultrasound examination was specifically requested for patients with RIF mass,
and patients with gynecological or urinary tract symptoms and those with
equivocal signs to exclude other pathology than acute appendicitis.7
Also urine analysis was done.
Patients with equivocal symptoms and signs were
kept under observation for 24 hrs, repeated TLC. And a decision was taken
either to operate or otherwise accordingly.
Patients proved with periappendicular mass were
treated conservatively,4 with repeated ultrasound examination and
daily recordings of pulse, temperature and close follow up, when abscess
diagnosed, patiens were operated on, otherwise interval appendicectomy was
carried out 6 weeks later.
All patients with the likelihood of perforated
appendicitis were started on intravenous fluids, nasogastric aspiration, and
triple antibiotics (ampicillin, gentmycin& metronidazole), which were
continued postoperatively for 7 days.5
A right lower paramedian laparotomy incision was
performed for perforated cases, peritoneal lavage by warm saline and drainage
through a separate stabwound.
Patients of acute appendicitis were operated
through a grid-iron incision and antibiotics started postoperatively. Patients
started on oral fluids after passage of flatus.
* Dept. of General Surgery, Faculty of Medicine, Sebha University, Sebha,
Libya..
Results:
In a prospective, study 128 patients diagnosed as
acute appendicitis were admitted and managed. 72 males, 56.25% and 56 females,
43.75% with a male to female ratio of 9:7, including all age groups and both
sexes ranging from 4-66 with mean 24 years. Males ranged from 5-55 with mean
24.5 years and female range of 4-66 with a mean 23.5 years.
Table No. 1 shows the age distribution per decade
with the largest age group in the 3rd decade, 44 patients, and 34.37
% of total.
117 patients were operated for acute appendicitis
and 11 patients presented with appendicular mass, have been treated
conservatively. Of the operated cases, 70 non-perforated, 59.82 %. 32
perforated, 27.35 % and 15 normal, 12.82 %. The highest incidence of
perforation in the 4th decade, 12 out of 32, 37.5 %. Of the 15
normal appendixes, 14 cases 93 % were female. 3 with positive findings-
terminal ileitis, acute salpingitis and a third subserous uterine fibroid.
The temperature and white blood cell counts were
important findings in our patients. Mean temperatures were elevated in all
cases of acute appendicitis complicated and non- complicated, in contrast to
normal appendix with mean temperatures in the normal range 37.3ºC. (Table No.
2).
The mean TLC count was elevated, 64.84 % had a
temperature > 10,000/mm3. Mean temperature of the total 11,108/mm3 with a
range 4x103-23x103/mm3. 73.3% of the normal cases had TLC
<10,000/mm3 that is expected. (Table No. 3).
Time from onset of symptoms till admission is
considered an important factor in development of complications. Table No. 4
shows a marked increase in mean time concerning complicated compared to
non-complicated acute appendicitis. Table No. 5 shows a remarkable rise in the
mean time from admission to surgery in consideration of perforated compared to
non-complicated acute appendicitis.
Hospital stay in days ranged between 2-29 for total
cases with a mean of 4.7 days. (Table No. 6).
Of the 117 patients operated as acute appendicitis,
7 patients developed wound infection for which the wound was opened and
drained. All were perforated. One patient developed chest infection, another
with residual pelvic abscess drained rectally and a 3rd had acute
renal failure with uncontrolled hypertension. No mortalities were reported.
(Table No. 7)
Age
incidence:
|
Age
|
Non- perf
+Mass
|
Normal
|
Perforated
|
Total
|
Incidence of perf %
|
|
1-9
|
7
|
1
|
6
|
14
|
42.8
|
|
10-20
|
23
|
5
|
9
|
37
|
24.3
|
|
21-30
|
35
|
7
|
2
|
44
|
4.54
|
|
31-40
|
11
|
2
|
12
|
25
|
48
|
|
41-50
|
3
|
0
|
2
|
5
|
40
|
|
51-60
|
1
|
0
|
1
|
2
|
50
|
|
> 60
|
1
|
0
|
0
|
1
|
0
|
|
Total
|
81
|
15
|
32
|
128
|
25
|
Table 1-A The Range is 4-66. The Mean is 24
years.
|
age
|
Males
|
Females
|
|
1-9
|
6
|
8
|
|
11-20
|
21
|
16
|
|
21-30
|
24
|
20
|
|
31-40
|
16
|
9
|
|
41-50
|
4
|
1
|
|
51-60
|
1
|
1
|
|
> 60
|
0
|
1
|
|
total
|
72
|
56
|
|
128
|
||
Table 1-B Age and sex incidence Males 56.25 % Females 43.75 %
|
Temp
|
Non-complicated
|
Perforated
|
Mass
|
Normal
|
Total
|
|
<38 c˚
|
38
54.28%
|
6
18.75%
|
4
36.36%
|
11*
73.33 %
|
59
46%
|
|
38-39 c˚
|
30
42.85%
|
23**
71.87%
|
7**
63.63%
|
4
26.66%
|
64
50%
|
|
>39 c˚
|
2
2.85%
|
3
9.37%
|
0
|
0
|
5
4%
|
|
Range
|
36.5-39.5c
|
37-40.8 c˚
|
37-39 c˚
|
36.5-38 c˚
|
128
|
|
Mean
|
37.7 c˚
|
38.4c˚
|
38 c˚
|
37.3 c˚
|
|
Table No. 2
Temperature distribution
* The highest percentage of cases with temp < 38
c˚ recorded with normal appendix 73.33%.
** It can be noticed that high percentage of cases
with temp 38-39 c˚ is recorded with
perforated 71.87% and mass 63.63 %.
TLC distribution
|
TLC
|
Non perf
|
Perforated
|
Mass
|
Normal
|
Total
|
|
<10,000
|
24
34.28%
|
6
18.75%
|
4
36.36%
|
11
73.3%
|
45
|
|
10,000-15,000
|
36
51.4%
|
17
53.1%
|
4
36.36%
|
3
20%
|
60
|
|
>15,000
|
10
14.28%
|
9
28.1%
|
3
27.27%
|
1
6.6%
|
23
|
|
Range
|
4000-19,500
|
4,000-23,000
|
5,700-22,000
|
4,000-19,000
|
128
|
|
Mean
|
10,624
|
13,211
|
12,577
|
8,980
|
|
Table No. 3
Time from onset till admission
|
Time
|
Ac.app
|
Perf
|
Mass
|
Normal
|
Total
|
|
<12 hrs
|
39
|
10
|
2
|
2
|
35
|
|
12-24 hrs
|
27
|
16
|
3
|
9
|
55
|
|
> 24 hrs
|
4
|
24
|
6
|
4
|
38
|
|
Range
|
1-48
|
3-96
|
7-192
|
2-96
|
1-192
|
|
Mean
|
12.3
|
24.4
|
59
|
30.4
|
21.48
|
Table No. 4
Time from admission till operation
|
Time
|
Acute appendicitis
|
Perforated
|
Normal
|
Total
|
|
<5hrs
|
20
|
8
|
2
|
30
|
|
5-10 hrs
|
32
|
14
|
6
|
52
|
|
> 10 hrs
|
18
|
10
|
7
|
35
|
|
Total
|
70
|
32
|
15
|
117
|
|
Range
|
1-48
|
2-72
|
3-72
|
1-72
|
|
Mean
|
8.8
|
15
|
18.4
|
11.8
|
Table No. 5
Only 117 cases out of 128 were operated.
11 cases treated conservatively as app. Mass.
Hospital stay in days
|
Days
|
Ac. app
|
Perf.
|
Mass
|
Normal
|
Total
|
|
< 5
|
64
|
7
|
3
|
12
|
86/ 67%
|
|
5-10
|
6
|
18
|
7
|
3
|
34/ 26.5%
|
|
> 10
|
0
|
7
|
1
|
0
|
8/ 6.25%
|
|
Range
|
2-6
|
3-29
|
3-11
|
2-6
|
2-29
|
|
Mean
|
3.1
|
7.9
|
6.45
|
3.8
|
4.7
|
Table No. 6
Postoperative complications
|
No.
|
Complication
|
Age (y)
|
Referred from
|
Appendicitis
|
Med. problems
|
Duration of symptoms.
|
|
1
|
Wound infection
|
40
|
Gatroun H.
|
Perforation
|
----
|
4d
|
|
2
|
Wound infection
|
12
|
Oubari H.
|
Perf/abscess
|
----
|
7d
|
|
3
|
Wound infection
|
7
|
Burgen H.
|
Perforation
|
----
|
8d
|
|
4
|
Wound infection
|
35
|
H.casuality
|
Perforation
|
----
|
3 hrs
|
|
5
|
Wound infection
|
18
|
H. Causality
|
Perforation
|
----
|
3d
|
|
6
|
Wound infection
|
34
|
H. Causality
|
Perforation
|
----
|
3d
|
|
7
|
Wound infection
|
32
|
H. Causality
|
Perforation
|
----
|
3hrs
|
|
8
|
Pelvic collection
|
40
|
Oubari H.
|
Perforation
|
----
|
2d
|
|
9
|
Acute renal failure
|
50
|
Murzok H.
|
Perforation
|
Hypertension
|
3d
|
|
10
|
Pneumonia
|
55
|
Murzok H.
|
Perforation
|
DM, SVT
|
4d
|
Table No – 7
Discussion:
In this study a male to female ratio is 9:7 or
1.28:1, this is comparable to 1.3: 1 by Rosemary et al.9 The rate of
normal appendix underwent surgery was 12.8% compared to 16%,9 14.5%3
and 15.9%.1 Female comprising 93 % others had 68 %.9
Perforated appendicitis represented 25% of the
operated cases with highest incidence in 4th decade 48%. Barouni1
had 20.1% incidence of perforation with highest incidence 47.3% in the 4th
decade. Perforation in children represented 42.8% compared to 46.6% by Barouni
and 47% by Gamal.8
The duration of symptoms is an important risk
factor for development of complications.The mean time for perforation and mass
is 24.4 and 59 hrs respectively, while 12.3 hrs for acute non-complicated
appendicitis.
The mean time from admission to surgery is 11.8 hrs
with high values for perforation 15 hrs and normal 18.4 hrs. We refer this to:
-
* Cases of appendicular mass on admission were
treated expectantly and only if signs of abscess develop are then operated.
Also a busy theatre with a single anesthetist.
A patient operated for normal appendix have the
highest mean time interval because of prolonged period of observation. Mean
hospital stay in days is 4.7 compared to 3.7 by others.3 Hospital
stay is prolonged with complicated cases 7.9 and 6.45 days.
Our postoperative complications represent 8.5 %,
wound infection represents 5.9%. 70% of complicated cases have symptoms for 3
days and more. Helmer et al2 found 9% incidence of wound infection.
Rosemary et al9 found 3% postoperative
complication and 47% patients with perforation.
Conclusion:
Proper knowledge and understanding of the pathology
and differential diagnosis of pain at right iliac fossa with special attention
to appendicitis and its early diagnosis by all doctors working in the
periphery, also early consultation are all among the important factors to minimize
morbidity associated with acute appendicitis.
References:
1. Barouni G. A.: Incidence of perforated
appendicitis. Jamahiriya. M.Journal. 2001, 1(1); 30-32.
2. Helmer K.S, et al:
Standardized patient care guidelines reduce infectious morbidity in
appendicectomy patients. Am. J. Surg. June 2002, 183(6): 608-613.
3. Ho.Hs:
Appendectomy. Scientific American Surgery. 1999, 1-18.
4. keddie N:
Management of appendicular mass. N. Br J Hosp. 1975, 175.
5. Krukowski
Z.H, Matheson N.A: Peritonitis. Surgery. 1984, 1,260.
6. Kevin G.
Bernard: Anthony E. Young eds, acute appendicitis. In: the new airds companion
in surgical studies. 1st ed. Churchill Livingstone London, New York,
1992, 908.
7. Puylaert
J. Rutgers P, et al: Imaging in acute appendicitis. N Eng J Med. 1987, 317:
666-669.
8. Reda
Jamal, Thomas C. Moore: Appendicitis in children aged 13 years and younger.
June 1990, 159(6): 589-592.
9. Rosemary
A. Kozar, Jod J. Roslyn: The appendix. In Schwartz. S. I et al (eds).
Principles of surgery. New York, London-McGraw Hill book Co. 7th ed.
1999, (2)1392.
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